Two years after the quake

PIH co-founder Paul Farmer reflects on Mirebalais and meliorism.

I’ve just returned from two brief trips to Haiti. Conditions there are harsh, but improving, and that’s cause for some joy. I wish to translate my own uplift into a New Year’s message of gratitude and determination. Because the backdrop is admittedly stark, it’s only fair to acknowledge the possibility that I am writing this to give myself hope and to spur all of us to launch, continue, or finish some ambitious and urgently needed projects. You know the phrase: hope is not a plan. But hope is, in our line of work, a necessary ingredient and sometimes the “secret sauce.” My time in Mirebalais, Cange, and Saint-Marc, our meetings with Haitian officials in the tiny trailer that now serves as the office of the country’s leading public health experts, and even yesterday’s commemorations of the two-year anniversary of the quake, gave me hope—hope worth sharing with all those who support a vision of building back better in Haiti. To see, in Mirebalais, a lovely and gleaming hospital and medical campus taking shape across what was once a bit of broken terrain running from steep conical hills down to an unproductive rice paddy—more of a swamp, really—is a stirring image for any visitor.

But it’s especially moving for one who remembers, as Partners In Health founders do, our modest and often discouraging beginnings in this very town. The time was 1983, the year that so many of us—Haitian and American and British—met in Mirebalais, the sleepy town where we tried to deliver quality medical services to people in great need of them.

It’s not easy to admit, even today: we tried and mostly failed. Sometimes we succeeded: a patient with acute malaria received chloroquine, a patient with scabies received the right topical medication, another patient’s fractured bone was set with competence and compassion. But if we look back honestly at our first years of hard work and 18-hour days, I’m not at all sure we can claim to have done a good job delivering quality health services. We were delivering something as hard and fast as we could, but surely the quality of the deliverables matters more than the good intentions of the caregivers or the pace of their work.

That was our conclusion when we closed the Mirebalais clinic in 1985 and started anew in Cange. And as we grew, we again faced serious problems of standards of care. Such problems have always been with us—and with all who seek to promote global health equity. We have a long, long way to go before we raise the standard of care to the level that our patients and their families deserve. But in the two years since the earthquake we have all worked hard to give substance to the hope that the quality of care we deliver in Mirebalais might be as good as anywhere else in the world. To make good on that hope, improvement in the quality of training programs and personnel is essential, but it cannot happen without a proper hospital. Put another way, it’s possible to deliver poor-quality medical care in a high-quality facility, but it’s probably not possible to deliver high-quality medical care in a poor-quality facility. After more than 25 years of working in the region, we will, along with our partners, have a first-class hospital there. Our efforts to drag up the standards of care in Mirebalais will benefit, I have no doubt, everywhere we work in Haiti (and many places where we don’t work). If central Haiti or northern Rwanda or rural Malawi or urban Lesotho teach us lessons about hospital construction, shouldn’t we be sharing these lessons with everyone who may be trying to do something similar? This alone would be a good set of New Year’s wishes for 2012.

THREE RESOURCES

We can entertain such wishes and see them through to fruition as long as we have three kinds of resources. Financial ones, of course. How else could we build (let alone run) a modern hospital in a place where clean water, electricity, and modern infrastructure are all but absent? Modern medical resources, obviously enough. How could we deliver modern medicine without the clinics and hospitals and the tools of the trade—preventives and diagnostics and therapeutics—made readily available to those who need them, regardless of ability to pay? But we also need human resources: well-trained and committed doctors and nurses and managers, and the greatest number of people on our payroll—those who run labs, take x-rays, and deliver services within the homes and villages of our patients, and also those who transport patients and specimens, who service and repair equipment, and who tend to the needs of patients and fellow employees alike.

The human resources challenge is perhaps the biggest one. Rural Haiti has long lacked trained medical professionals; even prior to the 2010 earthquake, most studies of this topic suggest that the majority of Haiti’s physicians and nurses have left the country altogether, and those who remain are concentrated in the capital city. (At the launch of a new family practice residency in Saint-Marc last week, the dean of Haiti’s oldest and largest medical school guessed that 80% of medically trained Haitians now reside outside the country.) The loss of Haiti’s nursing school to the 2010 quake, with heavy damage to other institutions of medical education, has worsened an already tough situation. To this end, we have worked to rebuild the training facilities destroyed during the quake and sought to reopen the UNIFA medical school, largely staffed by Cuban faculty. Just last month, we met with the Cuban Ambassador in Mirebalais. The Cubans have been the leaders in supplying long-term medical volunteers, and all of PIH/ZL’s public sites have benefited from the hard work of our Cuban colleagues. The ambassador committed a substantial number of specialists to help make Mirebalais a site of high-quality specialized medical care.

But the long-term goal, as we all agree, is building capacity locally, among young Haitian professionals. The Mirebalais National Teaching Hospital, like the new family practice residency in Saint-Marc (and others to follow), is meant to address this need over the next few years. But addressing problems locally—in a district or two—is never enough: once services are offered to the poor, the entire notion of “catchment area” or “district” falls out the window until the problems are addressed on a national level. This is the great dilemma of every Minister of Health, including our friends Dr. Florence Guillaume and Dr. Agnes Binagwaho in Haiti and Rwanda. They can and do encourage local initiatives, pilots, and real engagements to introduce new programs, but they can and must imagine, or re-imagine, health care delivery at the national level. Think of rural Rwanda or rural Haiti, with plenty of cancer, but zero oncologists. The establishment of “Centers of Excellence” (to use what is, alas, usually an aspirational term) able to deliver even the most basic cancer diagnosis and care lead to a national and even international stampede of patients and family members seeking expert mercy—diagnosis and comfort and cure (or at least care)—for ailments too often declared “untreatable” in poor areas. As was the case with HIV and MDRTB, every scourge that affects predominantly poor people is slated for similarly dismissive assessments from those seeking to carve up a tiny pie. Whether these discussions mark the beginning or the end of efforts to address problems as diverse as leukemia and cholera will depend on the success of efforts like those we’ve launched from hospitals in Peru, Haiti, Lesotho, Malawi, Rwanda, Russia, and elsewhere.

If this is such a noble effort, then why are we inhabited by anxiety? Hospitals, like health centers and community-based care, are needed, but they are larger, more expensive, more complex institutions to run. Our survival and growth depend on a massive bolus of new support. The complexity of hospital-based care is one of the reasons that global public health, and public health in general, starts with the low-hanging fruit. Low cost, high return: that’s why we’re always pushing bednets, vaccines, family planning, prenatal care, handwashing, and latrines. We will continue to cull the low-hanging fruit as best we can.

But the other ranking health problems, the higher-hanging fruit—from AIDS to drug-resistant tuberculosis to trauma to mental illness to cancer—cannot simply be wished away by the gurus of cost-effectiveness (the ones with the tiny pies). The low-hanging fruit hangs, after all, under a larger canopy of fruit. Do the models now dominant in global health permit us to harvest the higher-hanging fruit, from chronic non-communicable disease to new and explosive epidemics such as cholera in Haiti? Can we answer more of the need.

The short answer: of course we can, with innovation and resolve and a bolder vision than has been registered in public health over the past century. And that bold vision has a name: global health equity.

Some of you will remember PIH’s first mission statement, written 25 years ago. We pledged to link the vast resources of U.S. academic medical centers to the problems (many of them of the low-hanging varieties) of the destitute sick. Hence our most recent flagship project, a national teaching hospital in rural, central Haiti. All of our flagship projects, and indeed all of our work, should spring from our bedrock vision of global health equity. For example, the ambitious project we are seeking to launch with the Rwandan Ministry of Health draws on academic medical centers at Harvard and 16 other universities to train a generation of specialized doctors and nurses. The health centers and hospitals they staff will provide the sort of care that would be considered routine—mundane—in any community hospital in the United States, while simultaneously training large numbers of future health providers. The difficult, bracing, and promising integration of service and training and research is the heart of our history and the compass of our future.

PIH 3.0: LOOKING AHEAD

How might we best sustain our work over the next 25 years? What might PIH 3.0 look like? More correctly, what is Partnership 3.0? Although there’s not always full agreement about the notion of a “flagship” project, there is full agreement that our efforts are meant to improve the quality of services and grow from the principle of partnership. Sometimes, these are partnerships among service providers, teachers, and researchers—the original notion of “three pillars.” Always they are partnerships among people from very different backgrounds (within one country or across many). Sometimes the partnerships link different sorts of medical expertise (surgical, medical, psychiatric, and so on). Sometimes they bring together people who design and build hospitals—Jim Ansara has guided us since the early planning stages—with those who know how to power them with renewable energy or link them to the information grid. (Building a first-class hospital in central Haiti would have been unthinkable without skilled labor from the Dominican Republic, Ireland, the union halls of New England, Ann and Nicholas Clark Architects, Brigham and Women’s Hospital, and most of all, from Haiti.) Sometimes partnerships match expert managers and logisticians with those who seek to learn such skills. Always they depend on a broad and durable set of supporters, like the many individuals and organizations that have made generous in-kind and cash donations to our efforts in Mirebalais. (Marjorie Benton has helped us build new networks of support.) Above all, such partnerships link those who can serve with those who need services—and seek to bring the latter group into the former. That’s our “sustainability model.”

Why isn’t this transformative model—which would break the cycle of poverty and disease in part by moving people from “patient” to “provider” and from “needy” to “donor”—more widely embraced? Too often we see competition where partnership and cooperation are needed (and were promised). Too often we are all socialized for scarcity. Take the challenges of opening up rural Haiti’s first public teaching hospital. If key personnel are drawn from one institution in Haiti to help get Mirebalais up and running, the effects will certainly be felt. (Just as there were equally draining, and vociferously discussed, challenges in getting the Butaro Hospital in Rwanda on-line.) In every country in which we’ve worked, one effort or another, or one professional group or another (nurses or community health workers or generalists or lab personnel or residents), has occupied the place of “neglected stepchild” of PIH or Harvard Medical School or Brigham and Women’s Hospital or the global health movement or whatever parent organization is identified. But in our best moments, we the collective know that the term “neglected” applies, always and chiefly, to the poor, whatever their current ailments. We need to remember, over the coming years, that the preferential option for the poor needs not just to inspire but to drive our strategy. What is really neglected? Where are the gaps? Where does the burden of disease fall?

Let me give an example. Less than a decade ago, hardly a penny of aid money was devoted to taking care of people dying from the leading infectious cause of young adult death in the world: HIV disease. Now, AIDS is regarded as “overfunded” while other afflictions of the poor are regarded as somehow pushed to the side because too much money is going into AIDS prevention and care. This is absurd. A month ago I was lucky enough to award Dr. Louise Ivers the American Society of Tropical Medicine and Hygiene’s prestigious Ashford Medal, which was widely discussed within “the NTD community.” NTD stands for “neglected tropical diseases,” but on presenting the award I took the occasion to remind the audience that all diseases that afflict primarily the poor are by definition neglected. The idea that AIDS programs are overfunded is silly, since we have a long way to go before poor people living with AIDS have access to diagnosis and quality care. We’re not even halfway there. And yet, by 2004, when many public health professionals declared that AIDS was over-funded, there were probably almost zero poor people with AIDS—and the great majority of people with AIDS are poor—receiving publicly supported treatment or any meaningful treatment at all. Of course, such claims of overfunding were untrue, especially from the perspective of those living in the poorest parts of Africa or Asia or Latin America.

The reason I’m bringing up this fairly recent history is that we are all—the poor and those who serve them—socialized for scarcity. Some part of our brain assumes that if Mirebalais gets the lion’s share of attention—if it actually becomes a flagship project—then some other effort (Cerca Lasource, say, or Cange or Saint-Marc) must suffer. The same holds for elevating Butaro Hospital in Rwanda or the Tomsk prison in Siberia or one teaching hospital over another, or Malawi projects versus those in Lesotho.

But in our best moments, all of us know that this sort of thinking is wrong-headed. The Mirebalais National Teaching Hospital will not drag down the quality of care in the other settings in which we work, but will rather lift it up. We are so socialized for scarcity that we assume that if we focus on educating doctors we will neglect educating nurses (to say nothing of the other allied health professions, from laboratory technicians to community health workers). That if we focus on cholera vaccination we will neglect water and sanitation. That if we focus on research and teaching, service will suffer—when, again, we know in our best moments that simply adding training and research components to a service project, even one as straightforward as treating acute childhood malnutrition, will improve outcomes. We’ve shown it again and again, and so has every other group taking the trouble to study the impact of research and training on quality of care.

And that’s just talking about what everyone thinks of as health care. But every care provider—nurse or doctor or social worker or community health provider—working on the frontlines of global health knows full well that the great majority of our patients’ clinical problems are directly linked to poverty. Hence PIH-affiliated projects like “A Thousand Jobs for Haiti” or the Fritz Lafontant Vocational School or Zanmi Agrikol or the Nourimanba plant supported by Abbott Laboratories/Abbott Fund or the fish farms in Boucan Carré and Zanmi Beni. Hence scholarly work in Rwanda to try to document collateral benefits that investments in health and education provide for economic development. Hence our peculiar obsession with the efflorescence of hotels, small businesses, beauty shops, and other small enterprises around PIH-affiliated hospitals. Hence our efforts to bring friends like Joey Adler, Denis O’Brien, and Donna Karan to rural Haiti as not just as donors but also as investors looking for businesses that can and will lessen the burden of premature suffering and death among those we serve. The people we serve don’t yet have jobs in the generative sector beyond agriculture. But they will.

Where joblessness is the status quo, building new hospitals and health centers and schools can bring disappointment to some: everyone wants to work there—and usually not because they want a better job, but because they want a job, period. Before joining us, the majority of PIH’s 15,000 employees never held a salaried job in what economists term the “formal sector.” Meaning they’d never earned a salary for their work, as do most of those who will read this. Our colleagues are also socialized for scarcity—the assumption that if someone else gets a job, even someone in their own family, then they will not. This sort of limited-good, zero-sum thinking is to be expected among the poor, but is unacceptable from those who seek to attack poverty. Too many of these experts display a worshipful regard for cost-effectiveness analysis, no matter how banal or unscientific in terms of rigorous assessment of either cost (how big or rigid is the pie, really?) or effectiveness. Too many experts in public health have failed to scrutinize the way that capital, like microbes, moves. Few of us have endured real scarcity or lived on the edge of survival. But for those seeking jobs in Mirebalais and elsewhere in our global network, getting a job is a matter of survival. Turning health care needs into much-needed jobs is sure to be a core principle of Partnership 3.0.

CURBING CHOLERA

Finally, a word about cholera. With the mission statements of PIH and our closest Harvard affiliates in mind, it was obvious that we needed to mobilize all effective deliverables and pull together all potential partners to prevent a major epidemic in the Americas. We failed to do that, and Haiti now endures the world’s largest cholera epidemic in recent history. Socialization for scarcity in responding to cholera has had the same pernicious effects—pitting water projects against vaccination, one form of treatment against another—I’ve just described. What is needed, rather, as we’ve all argued from the beginning of the epidemic, is an aggressive and integrated approach that might lead in a decade or so to the eradication of a disease previously unknown in Haiti and the Dominican Republic. An integrative approach would help in other cholera hotspots, too. As of this past month, the Haitian Ministry of Health has vocally supported the modest vaccine roll-out that we are doing in concert with them and with GHESKIO, another medical nonprofit that has worked in Haiti for more than two decades. Integrating vaccination into an ambitious water and sanitation effort would surely reduce fatality rates and slow the epidemic. That itself would be a victory. But we also hope to show how this cholera vaccine effort might strengthen the national vaccination program (low-hanging fruit again), and generate new knowledge about how to stop cholera and other vaccine-preventable illnesses across Haiti and elsewhere in the world. We hope to bring down the price of the vaccine and relevant medications, to control all waterborne diseases, and to lead efforts for a global stockpile of vaccine for Haiti and for other cholera-afflicted countries in Asia and Africa.

It’s no accident that the NGOs leading this charge are the very two that link direct service to the poor to training and research; that they are formally affiliated with research universities of global repute; and that they work closely with the Ministry of Health. No one imagines the cholera vaccine initiative will be easy, especially given the need for meticulous monitoring and evaluation and the need to accomplish the basics before the next rainy season in a couple of months. But we can succeed by drawing on the core competencies of PIH—delivering service to the most vulnerable, training others to do so, and improving quality of care through feedback loops—and of its key partners, which include, of course, the MOH, but also community organizations, academic medical centers, and research universities like Dartmouth and Duke.

EXISTING WORK, NEW PROJECTS

Building hospitals, starting new training programs, launching a new vaccination effort, and simply keeping other projects going requires more effort and energy when many of us, especially the post-quake Haiti team, are worn down; it requires renewed commitment to working with new partners when we all know how much energy existing partnerships consume. It requires a subtle shift in focus: not so much shrinking our service commitments but growing our training and research efforts in order to continue delivering quality health care. No PIH service project should be unleveraged by formal training programs and research. That’s what our original mission statement, written 25 years ago this year, promised. And it remains a noble goal.

We have always prided ourselves on keeping our operating expenses low. But raising the ambitions of our installations requires spending more on managing them, on recruiting personnel, on designing programs that serve patients.

Finally, none of our ambitious programs should be curbed by the pernicious notion of goodness as a limited commodity. We need to expand the notion of good and the notion of excellence and the idea that one flagship project might raise the aspirations of all of our efforts. The launch of the Mirebalais Hospital will permit us to improve the quality of our infrastructure from Belladère to Saint-Marc. Each of these sites needs significant physical plant improvements, just as our staff needs (and deserves) more continuing education to improve the quality of the services we offer.

On the intellectual and philosophical level, none of this is news. PIH supporter Bob Richardson (husband of another of our greatest supporters, Annie Dillard) has written a wonderful biography of William James, which I’d like to quote in closing:

In one of his talks to teachers he said, “Spinoza long ago wrote in his Ethics that anything that a man can avoid under the notion that it is bad he may also avoid under the notion that something else is good. He who acts habitually sub specie mali, under the negative notion, the notion of the bad, was called a slave by Spinoza. To him who acts habitually under the notion of good he gives the name of freeman. See to it now, I beg you, that you make freemen of your pupils by habituating them to act, whenever possible, under the notion of a good.”

Acting under the notion of good, in places like rural Haiti or Rwanda or Malawi or urban Peru or the United States or Russia, is our task. Acting under the notion of good does not provide us with a ready-made strategic plan for our next 25 years of work. But it does help us to cultivate the hope and optimism—the “meliorism”—that underpins our efforts to improve the quality of our services. And that’s the main thing we need to meet our mission.